Valvulitis: a new echocardiographic criterion for the diagnosis of prosthetic valve infective endocarditis

Abstract

Abstract Background Diffuse homogeneous hypoechoic leaflet thickening, with a wavy leaflet motion documented by transesophageal echocardiography (TEE), has been previously described in some patients with aortic bioprosthetic valve endocarditis (PVE). This echocardiographic finding has been termed valvulitis. Objectives Our aim was to estimate the prevalence of valvulitis, to precisely describe its echocardiographic characteristics, and to determine their clinical significance in patients with aortic bioprosthetic valve endocarditis. Methods From 2011 to 2022, 388 consecutive patients with IE admitted to a tertiary care hospital were prospectively included in a multipurpose database. For this study, all patients with aortic bioprosthetic valve endocarditis (n=86) were selected, and their TEE images were thoroughly evaluated by three independent cardiologists to identify all potential cases of valvulitis. The diagnosis of valvulitis was considered to be present when all three were in complete agreement. Results Prevalence of isolated valvulitis in the total cohort was 12.8%, and 20.9% of patients had valvulitis accompanying other classical echocardiographic findings of IE. A description of the main clinical and imaging findings of 11 patients with valvulitis and no other echocardiographic signs of IE is shown at the Table. Diagnosis status corresponds to the criteria for the diagnosis of IE according to the ESC 2015 IE guidelines, including 18F-FDG PET/CT. TEE long-axis and short-axis views of a patient with bioprosthetic valvulitis (homogeneous and hypoechoic thickening of the aortic leaflets) resulting in severe aortic stenosis are shown at the Figure, Panel A. At Panel B, abnormal FDG uptake (white arrow) at the prosthetic valve is seen on PET/CT scan of the same patient. At Panel C, histology of the aortic bioprosthetic leaflet of the same patient with valvulitis is presented (hematoxylin and eosin stain of the aortic leaflet; granulation tissue is well demonstrated (red bracket) covering the aortic fibrosa (red asterisk)). Moderate or severe valve stenosis was more common in those with valvulitis (81.8 vs 34.9%, p<0.001). Patients with isolated valvulitis tended to have a lower IE-related in-hospital mortality (9.1 vs 23.3%, p=0.219) and cardiac surgery was less frequently performed than in the other subjects with aortic PVE (27.3 vs 58.1%, p=0.17), but these results were not statistically significant. Conclusions Valvulitis can be the only echocardiographic finding in infected biological aortic prosthesis and needs to be recognized by imagers for early patient diagnosis. The identification of this sort of lesion is important since the clinical profile and management of these patients is different from that of patients with classical PVE.TableFigure